Reason for Not Initiating Antenatal Steroid Therapy

Specifications Manual for Joint Commission National Quality Measures (v2015A)

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Release Notes:
Data Element
Version 2015A

Data Element Name:

Reason for Not Initiating Antenatal Steroid Therapy

Collected For:

PC-03,

Definition:

Reasons for not initiating antenatal steroid therapy before delivery are clearly documented in the medical record. Reasons for not initiating antenatal steroid therapy may include fetal distress, imminent delivery or other reasons documented by physician/advanced practice nurse (APN)/physician assistant (PA)/certified nurse midwife (CNM).

Initial antenatal steroid therapy is 12mg betamethasone IM or 6mg dexamethasone IM.

Suggested Data Collection Question:

Is there documentation in the medical record of reasons for not initiating antenatal steroid therapy before delivery?

Format:

Length:	1
Type:	Alphanumeric
Occurs:	1

Allowable Values:

Y (Yes) There is documentation by physician/APN/PA/CNM that the patient has one or more reasons for not initiating antenatal steroid therapy before delivery.

N (No) There is no documentation by physician/APN/PA/CNM of a reason for not initiating antenatal steroid therapy before delivery or unable to determine from medical record documentation.

Notes for Abstraction:

When determining whether there is a reason documented by a physician/APN/PA or CNM for not initiating antenatal steroid therapy, reasons must be explicitly documented (e.g., "patient had an adverse reaction to the medication in the past - unable to initiate antenatal steroid therapy") or clearly implied (i.e., there is documentation of an imminent delivery which occurs within 2 hours after admission to the hospital, there is documentation the fetus has anomalies which are not compatible with life, there is documentation that the patient has chorioamnionitis).

Suggested Data Sources:

PHYSICIAN/APN/PA/CNM DOCUMENTATION ONLY

History and physical
Physician progress notes
Prenatal forms

Additional Notes:

Guidelines for Abstraction:

Inclusion	Exclusion
None	None

Reason for Not Initiating Antenatal Steroid Therapy

Specifications Manual for Joint Commission National Quality Measures (v2015A)
Discharges 01-01-15 (1Q15) through 09-30-15 (3Q15)